Abuse of any kind can do irreparable harm to a patient's physical and psychological health, destroy social and family ties and lead to devastating financial loss. Older victims, in particular, have been shown to die earlier than those who have not been abused. The following article is the fourth in a series of stories designed to shed light on the escalating and often-overlooked global issue of elder abuse and neglect — physical, sexual, emotional and financial. Our aim is to increase provider awareness and improve the detection and management of at-risk geriatric patients.

Cleveland Clinic geriatrician Ronan Factora, MD, recalls treating an older patient who was struggling to manage his daily activities. An amputee who lived alone and was dependent on a motorized wheelchair, the man was struggling to feed and bathe himself, manage his diabetes medications and seek medical care. Socially isolated and afflicted with declining vision, the patient was referred to Dr. Factora’s clinic after a concerned neighbor reported the situation to adult protective services (APS).

Unfortunately, healthcare providers who manage older adults may find cases like this one to be all too familiar.

Neglect is the most common form of elder abuse, yet its often-subtle signs frequently go undetected. Classic indicators of neglect, including an unkempt appearance and a growing reliance on emergency services, are frequently misinterpreted in older patients, but their consequences can be profound and far-reaching, Dr. Factora explains. By remaining attuned to red flags and intervening early, however, providers can make a significant difference in the health and outcomes of their geriatric patients, he says.

“Neglect can be every bit as dangerous as physical abuse, but it is far more likely to be overlooked,” he says. “Over time, these patterns can weaken social and family ties and compromise a patient’s physical and psychological health, so it’s incumbent on healthcare providers to remain vigilant when evaluating older adults.”

Neglect and self-neglect are related concerns that frequently overlap. In some cases, trouble arises when an assigned caregiver, such as a spouse or family member, is tasked with keeping an older patient safe, providing food and transporting them to medical appointments. Neglect can occur when the caregiver is unable – or unwilling – to fulfill those basic requirements, Dr. Factora explains.

“The caregiver may be trying, in earnest, to do the right thing – but at some point, the patient’s needs can exceed the caregiver's capability,” he says.

Self-neglect is often seen in older adults who are socially isolated and unable to care for themselves, typically due to physical limitations or cognitive decline. Unfortunately, self-neglect may persist for months or even years before it’s discovered, Dr. Factora notes, largely because of the patient’s inability to recognize the risks posed by their own behavior.

Although there is no single pattern of elder neglect, its common physical and emotional warning signs should raise suspicion in observant providers, Dr. Factora says. He stresses that timely interventions can significantly improve a vulnerable patient’s quality of life by ensuring their basic needs are met.

Unexplained weight loss can suggest that an older adult is failing to receive adequate nutrition or is simply forgetting to eat. The patient may not recognize these inconsistencies as problematic and may even express pride over the lost pounds, so Dr. Factora encourages providers to regularly log their patients’ weight while evaluating for visual cues, including ill-fitting clothes, that may point to insufficient caloric intake.

Ongoing trouble in managing chronic conditions may also point to potential neglect. Missed medications, for example, can be a sign of self-neglect or a caregiver’s inattention or unwillingness to provide the required treatment, Dr. Factora says. Unusual lab results, abnormal blood pressure or glucose readings, disease exacerbations and frequent emergency department visits are additional red flags, especially when the patient’s medical conditions have been historically well managed, he adds.

Dr. Factora also encourages providers to communicate openly with their patients’ caregivers, probing further if signs of stress or overwhelm are detected.

“We know proper caregiver support can significantly reduce burnout and improve the at-home management of aging adults,” he adds. “Family members struggling to cope with their caregiving role may benefit from the support of community resources.”

Dr. Factora emphasizes that any time neglect is suspected, the most important thing providers can do is act. “Signs of neglect are often dismissed in geriatric patients and may be misinterpreted as part of the normal aging process,” he says. “While problems with hygiene, nutrition and medication compliance may result from a patient’s disease or declining cognitive function, their appearance should prompt further investigation.”

He notes that clinicians can provide invaluable help by linking patients and caregivers to community resources or referring them to a social worker who can offer additional support and help them create a care plan. If self-neglect is suspected, the provider’s first call should be to APS, Dr. Factora says.

“Because self-neglecting individuals seldom have the wherewithal to follow through and make the phone calls necessary to bring additional resources into the home, outside intervention is usually required,” he explains.

When contacting APS, reporting clinicians are advised to provide as much detail as possible about the patient’s situation and continue to check in to ensure the case is addressed. Patients in whom neglect is suspected also warrant closer monitoring, including more frequent follow-up visits, Dr. Factora says. Ideally, a nurse or other member of the care team should remain in regular contact with the patient.

Conditions improved for Dr. Factora’s wheelchair-bound patient with the aid of APS. The man was referred to Meals on Wheels, which improved his eating habits and nutritional intake, and he was referred to an adherence pharmacy, which made it easier for him to stay on track with his medications.

The care team helped the patient arrange transportation to his medical appointments and connected him with Veterans Affairs for additional support after learning he had served in the military. Because the patient had difficulty using the phone, Dr. Factora’s team also provided him with a personalized safety plan to ensure he could access emergency medical services when needed

Ultimately, the interventions improved the patient’s well-being and enabled him to continue living at home, Dr. Factora notes.

“Cases like this are important reminders that clinicians can be a critical line of defense in the lives of geriatric patients,” he says. “Such interventions work best when provided in collaboration with a team of other caregivers who understand how to connect at-risk patients with appropriate social services and are prepared to follow up to ensure their needs are being met. When we all work together, we can help preserve the dignity and safety of older adults.”